Wiki Review of Systems - Documentation for Complete ROS

[gena379]

Guidelines say: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation of indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

There are 14 possible systems to be reviewed. Does this statement mean that to get credit for a complete ROS you have to individually document the 10 systems and then all remaining (4) can be documented as "all other systems negative)?

I have always allowed my providers to document the pertinent +/- (however many that may be) and then state "all other systems negative" to get credit for a complete ROS. A coder on our team is reading the guidelines differently so we thought we'd see how others interpret this.

Thank you,

 

[ellzeycoding]

This means you have to review 10 systems total.

You document the pertinent positive and negative responses... this could be 2 or 3 or 1, and then you can write all other systems are negative.

So you have to ask about at least 10. You can have any number of pertinent responses (which you document). Then you can write "all other systems negative" for the remainder that you didn't document.

 

[gena379]

That's how I've been doing it. Perfect. Thank you!

Gena